Military Medical Might: Indonesia to Haiti

A populace is devastated by natural disaster, without access to medical care for trauma and infectious disease. Physicians and nurses from around the world rush to help, but good intentions are handicapped by logistical challenges – a lack of diagnostic technology, operating room facilities, and clean environments where the severely injured can recover. To alleviate the medical crisis, the U.S. Navy sends one of its two massive floating hospitals, which sits offshore and starts providing advanced medical care for survivors of the disaster with the help of volunteers from non-governmental organizations in a unique military/civilian partnership.

That, in a nutshell, is the current situation in Port-au-Prince, Haiti. But, according to Matthew Wynia, assistant professor of infectious disease at the University of Chicago Medical Center, it could also describe the situation five years ago in Banda Aceh, Indonesia, in the weeks after a deadly tsunami killed as many as 170,000 people in the country. In the rush to provide critically-needed medical resources to the region, strange bedfellows were made between the U.S. Navy and Project HOPE, an international health care organization that provides medical care to developing countries. As part of that effort, roughly 100 physicians and nurses from around the world worked from the USNS Mercy, a Navy hospital ship, to treat the wounded of Banda Aceh – a mission that set the mold for efforts such as the current use of the USNS Comfort to treat survivors of the Haiti earthquake.

Banda Aceh after the 2004 tsunami

Wynia, also director of the Institute for Ethics at the American Medical Association, spoke about that experience Wednesday as part of the MacLean Center for Clinical Medical Ethics weekly lecture series. In light of current events, the talk was particularly interesting – though the Medical Center teams in Haiti are not working from the USNS Comfort, they will be receiving patients discharged from the ship to clear space so that more people can receive operations and care. Usefully, Wynia recapped his experience with candor, addressing the ethical issues that faced medical volunteers working alongside the U.S. military administering care to a nation wary of American intentions.

At the end of 2004, when the tsunami struck Indonesia, public opinion of the heavily Muslim country about the United States was precariously low: only 15 percent positive, Wynia said. What’s more, the country had been in the midst of a civil war before the disaster, and neither side particularly welcomed a naval ship nearly the size of an aircraft carrier floating only 2 miles off shore. As a result, the ship was only allowed to be in Indonesian waters for 90 days following the tsunami, and given the time it takes to sail a gigantic ship from San Diego to Indonesia, it didn’t arrive until a month after the disaster.

By that point, as with the current situation in Haiti, many of the severe trauma victims had already undergone surgery or succumbed to their injuries, Wynia said. As such, despite the fact that the USNS Mercy was equipped to serve as a floating trauma center for severe war injuries, the medical team only saw 300 operating room cases during their 60 days off Banda Aceh. On a ship equipped with 1000 hospital beds (though as Wynia pointed out, half of them were upper bunks unsuited for severely-ill patients), only 170 inpatient admissions were made. Much of the care supplied by the physicians and nurses was either diagnostic (using the state-of-the-art CT scanner on board) or primary care – providing dental care, eyeglasses, and prescriptions for management of chronic disease.

The USNS Mercy alongside the USS Abraham Lincoln

Part of that focus on intermediate emergencies and routine medicine was born from political caution – the Navy was very determined that no patients died on the ship, Wynia said. Officials wanted to avoid the scandal of someone being taken to the USNS Mercy never to return, necessitating a “very careful triage” on shore by doctors and officers determining who would be transported by helicopter to the ship. That was a policy that left many volunteers uneasy, Wynia said, but a precaution that may have been necessary in a country where a child in an Osama Bin Laden t-shirt was not an uncommon sight.

“The military and the U.S. government at the time did not want anyone to die on the ship, and you can imagine why,” Wynia said. “You get airlifted away from your family and friends, you go out to the American ship and you die. That doesn’t look good, especially in an environment where people are tremendously distrustful of the U.S. at the outset.”

Other ethical dilemmas included the usual language barriers and the struggle to obtain informed consent from a population not used to playing a role in their own health care. A massive question was the cost-to-benefit ratio – Wynia estimated the cost of the mission at somewhere between 20 and 40 million dollars. But medical outcomes were only part of the military’s goals in supporting the effort, Wynia said.

“The reality is there were multiple missions going on here,” Wynia said. “We wanted people to like the United States again, to see the good United States.” As the commanding officer of the ship put it, “This was leading with our hearts, not with our fists.”

That effect could be measured through the same polls that once showed overwhelmingly negative opinions of the United States. The 15 percent approval rate rose to 40 percent over the course of the mission, as Indonesians in Banda Aceh and elsewhere saw the good that the USNS Mercy (and thousands of doctors from other organizations on shore) were doing. Less cynically, an Indonesian interpreter assisting the effort read a letter to the crew emphasizing how even the most basic medical care provided intangible benefits to the people they treated.

“For the first time, they are aware of their worth as people, that their thoughts and feelings and lives count,” the interpreter wrote. “When they leave here, they know they are valuable, they leave with self-esteem. This is something very special and very rare you’ve given them.”

“It was something that none of us had actually even thought about until she raised this issue,” Wynia said. “That the U.S. standards of care – at their best, at least – involved respect and honesty and communication and efforts to engage the patient in decision-making about their own care. This was someting that was life-altering for some of the patients we saw…and by the way, not particularly high-tech. That’s an aspect of U.S. standards of care that we can bring anywhere.”